12 SECTION I Pediatric Critical Care The Discipline resuscitation skills during pediatric residency through the use of rapid cycle deliberate practice in simulation training127 as well as retention of[.]
12 S E C T I O N I Pediatric Critical Care: The Discipline resuscitation skills during pediatric residency through the use of rapid-cycle deliberate practice in simulation training127 as well as retention of skills in pediatric trauma management months after simulated pediatric trauma education in emergency departments.128 Researchers at the University of Michigan have demonstrated significant correlation between simulation-based education and a 50% improvement in pediatric patient cardiopulmonary arrest survival rates.129 Simulation continues to grow in the education of pediatric residents, fellows, and attendings worldwide as a platform for mastery through deliberate practice providing the opportunity for immediate feedback in high-risk, low-frequency events without compromising patient safety Many pediatric intensivists have contributed to local and national organizations and have been rightfully recognized for that Some of the individuals from organizations in the United States are listed in Tables 1.3 through 1.6 TABLE Chairs, Pediatric Critical Care Medicine 1.3 Subboard, American Board of Pediatricsa 1985–1987 Peter Holbrook, MD 1988–1990 Bradley Fuhrman, MD 1991–1992 Thomas Green, MD 1993–1996 Ann Thompson, MD 1997–1998 TABLE Chairs, Executive Committee, Section on Critical 1.5 Care Medicine, American Academy of Pediatrics 1984–1987 Russell C Raphaely, MD 1987–1990 Fernando Stein, MD 1990–1992 J Michael Dean, MD 1992–1996 Kristan Outwater, MD 1996–2000 Timothy Yeh, MD 2000–2004 M Michele Moss, MD 2004–2008 Alice Ackerman, MD 2008–2012 Donald Vernon, MD 2012–2016 Edward Conway Jr, MD 2016–2018 Michael Agus, MD 2018–2021 Elizabeth Mack, MD TABLE Chairs, Pediatric Section, Society of Critical Care 1.6 Medicine 1980–1981 Russell C Raphaely, MD 1981–1983 Peter R Holbrook, MD 1983–1984 Bernard Holtzman, MD 1984–1985 Bradley Fuhrman, MD Daniel Notterman, MD 1985–1986 Frank R Gioia, MD 1999–2000 David Nichols, MD 1986–1987 Timothy S Yeh, MD 2001–2002 Jeffrey Rubenstein, MD 1987–1988 Fernando Stein, MD 2003–2004 Alice Ackerman, MD 1988–1989 Thomas B Rice, MD 2005–2006 Donald Vernon, MD 1989–1991 Ann E Thompson, MD 2007–2008 Karen Powers, MD 1991–1994 J Michael Dean, MD 2009–2010 M Michele Mariscalco, MD 1994–1996 Debra H Fiser, MD 2011–2012 Laura Ibsen, MD 1996–1998 Thomas P Green, MD 2013–2014 Susan Bratton, MD 1998–2000 Daniel A Notterman, MD 2015–2016 James Fortenberry, MD 2000–2002 Richard J Brilli, MD 2017–2018 Jeffrey Burns, MD 2002–2004 M Michele Moss, MD Folafoluwa Odetola, MD 2004–2006 Stephanie A Storgion, MD 2006–2008 Edward E Conway Jr, MD 2008–2010 Vicki L Montgomery, MD 2010–2012 Jeffrey P Burns, MD 2012–2014 Ken Tegtmeyer, MD 2014–2016 Derek Wheeler, MD 2016–2018 Thomas A Nakagawa, MD 2018–2020 David A Turner, MD 2020–2022 Alexandre T Rotta, MD 2019–2020 a Medical Editor, 1985–2004, George Lister, MD; 2004, Jeffrey Rubenstein, MD TABLE Pediatric Intensivists Serving as President 1.4 of Society of Critical Care Medicine 1982–1983 George Gregory, MD 1984–1985 Dharmpuri Vidyasagar, MD 1988–1989 Peter R Holbrook, MD 1992–1994 Russell C Raphaely, MD 2001–2002 Ann E Thompson, MD 2004–2005 Margaret M Parker, MD 2018–2019 Jerry J Zimmerman, MD Cost of Success in Pediatric Critical Care Medicine Everything comes at a cost In the field of PCCM, as in many others, advances have led to increased financial cost, survivors with chronic disease, medical errors, and occasional dehumanization of 12.e1 Canada As described earlier, Dr Alan Conn, anesthetist-in-chief at the Hospital for Sick Children, Toronto, envisioned and successfully opened a multidisciplinary PICU for medical and surgical patients in 1971.138 At the Children’s Hospital of Montreal, a medical PICU was created in 1972 by a pediatrician, Dr Michael Weber, and pulmonologist Dr Andre Lamarre Drs Marie Gauthier, Jacques Lacroix (University of Montreal), and John Gordon (McGill University) in 1992 were active in the development and implementation of a fellowship program in PCCM supervised by the Royal College of Physicians and Surgeons of Canada.139 South Africa As noted earlier, in 1959 Drs P.M Smythe and Arthur Bull conceived a brilliant therapeutic plan to treat infants afflicted with neonatal tetanus from infected umbilical cord stumps.26 Dr Max Klein continued their tradition at Red Cross Children’s War Memorial Hospital, opening a special unit for critically ill children in 1974 with full-time intensivists Drs Louis Reynolds, Jan Vermeulen, Paul Roux, and, later, Andrew Argent.4,5,140 Japan In the 1960s, Dr Seizo Iwai, chief of anesthesia at the National Children’s Hospital in Tokyo, was the first Japanese physician to introduce mechanical ventilation and arterial blood gas analysis of critically ill infants, fostering a tradition of anesthesiologists taking care of critically ill infants and children outside of the operating room He was a strong force in developing a close relationship with other Asian countries, inviting trainees from those countries to promote teaching and pediatric critical care development in their homeland His close working relationship with Drs Conn and Barker in Toronto paved the way for Dr Katsuyuki Miyasaka to study in Toronto with Dr Conn and in Philadelphia with Dr Downes Dr Miyasaka returned to Japan in 1977 In October 1994, he opened the first geographically distinct PICU in Japan at the National Children’s Hospital and helped to found the Japanese Society of Pediatric Intensive Care Dr Miyasaka continues to foster the development of a new generation of pediatric intensivists as a hospital director, playing a major role in facilitating this process.141 India Neonatal intensive care units (NICUs) in India were established in the 1960s, first at the All India Institute of Medical Sciences, Delhi, and subsequently at teaching hospitals in other major cities.142–144 The first PICUs were established at major postgraduate centers (Delhi, Chennai, Chandigarh, Mumbai, and Lucknow).145 Growth of PICUs had been mainly in the private sector, although major government teaching hospitals are also improving the PICUs in their locations An intensive care chapter of the Indian Academy of Pediatrics was formed in 1997 The Pediatric Section of Intensive Care of the Indian Society of Critical Care Medicine (ISCCM) was formed in 1998.146 There are four streams of formal training available: (1) a 3-year doctor of medicine program at three institutions, (2) a 2-year fellowship offered at 12 centers by the National Board of Examinations, (3) 1- and 2-year fellowships offered at 33 centers by the College of Pediatric Critical Care, and (4) a 1-year fellowship offered at 18 centers by the Indian Academy of Pediatrics— Intensive Care Chapter.147,148 Whereas the government-supported transport service has spread to many states, it transports PICU patients to government hospitals only There is a growing awareness that outcomes are better if patients are transported by specialized teams; therefore, an increasing number of critically ill children are transported by dedicated transport teams maintained by major PICUs in private hospitals.149 Australia and New Zealand As in the United States and Canada, Australian PICUs started forming in the early 1960s, arising from wards that performed postoperative recovery care for children following congenital heart surgery,150–157 with continuing development of PICUs in major cities There was creative development in many centers throughout Australia, some of which are in Melbourne, Adelaide, Camperdown, Brisbane, and Perth We will present some of the history and refer the reader to a more detailed account with AUSPIC News edited by Frank Shann in 1993.150 At the Free Hospital for Sick Children Melbourne, pediatric anesthesiologists Jan H McDonald and John Stocks in 1963 developed a 10-bed multidisciplinary PICU They conducted clinical studies, including a large study demonstrating the safety and efficacy of oral and nasal plastic endotracheal tubes for airway management of children requiring mechanical ventilation.158 In Adelaide Children’s Hospital, Australia, in the early 1960s, Tom Allen and Ian Steven from the Department of Anesthesia began treating upper airway obstruction with prolonged oral and then nasal intubation.159 Long-term mechanical ventilation using Bird ventilators commenced in 1963.160 Pediatric intensive care was established at Princess Margaret Hospital in Perth by Nerida Dilworth (anesthesia) in the early 1960s Prolonged nasal intubation was first performed in September 1963 In May 1969, a dedicated area in one of the medical wards was set aside for the care of critically ill children The first full-time intensivists were appointed in 1986 (Alan Duncan, director, and Paul Swan, specialist) The modern 10-bed PICU was opened in April 1987.161 Matthew Spence, an anesthesiologist originally from Glasgow, pioneered critical care medicine for adults and children in Auckland Hospital, New Zealand, opening the first adult and pediatric ICU in 1958 Cardiac surgery for children in New Zealand started at Green Lane Hospital, Auckland, in the 1950s A dedicated intensive care unit was established there in 1963, led by the cardiac surgeon Sir Brian Barrett-Boyes and anesthesiologists Drs Marie Simpson and Eve Scelye The first specialized pediatric emergency transport service commenced in Victoria in 1980.162–166 In March 1991, Elizabeth Segedin was appointed as a full-time pediatric intensivist (with no PICU!) to plan for the development of a pediatric unit With the building of the new hospital for children in Auckland, intensive care for children was reorganized to a single PICU at the Starship, which opened on December 2, 1991, with Dr Segedin as director Europe In Europe, pediatric intensive care followed shortly after the poliomyelitis epidemic in Denmark in 1952 As described 12.e2 previously, in 1955 Dr Goran Haglund, a pediatric anesthesiologist, established the first medical-surgical PICU for infants and children at the Children’s Hospital in Göteborg in Sweden.18 In 1961, Dr Hans Feychting, also a pediatric anesthesiologist, established the first PICU at St Goran’s Children’s Hospital in Stockholm, Sweden, and became recognized as a pioneer in the development of pediatric intensive care in Europe In France, in 1963, a newborn presented with tetanus and was admitted to L’Hôpital des Enfants Malades of Paris Shortly afterward, Dr Gilbert Huault and J.B Joly, both neonatologists, opened the first multidisciplinary PICU in France at Saint Vincent de Paul Children’s Hospital This unit was the first pediatrician-directed PICU in Europe; it soon became a major influence on the development of PICUs Drs Francois Beaufils, Jean Christophe Mercier, and Denis Devictor were to play an important role in further development of European pediatric critical care medicine.167 In London, a pediatric anesthesiologist, William Glover, opened a unit for care of postoperative cardiac patients in 1961 at the Hospital for Sick Children on Great Ormond Street Soon, all patients needing ventilator care were admitted to that unit.168 In 1964, a well-designed discrete 13-bed PICU was developed by Dr G Jackson Reese, a pediatric anesthesiologist, at the Alder Hey Children’s Hospital in Liverpool Other units soon followed, essentially serving as areas allowing prolonged postoperative support.169 In Spain, pediatrician Dr Francisco Ruza started working in neonatal surgical intensive care in 1969 In 1976, he opened a multidisciplinary medical-surgical PICU for older infants and children at Hospital Infantil La Paz in Madrid This center, directed by Dr Ruza, has served as a major training center for pediatric intensivists not only from Spain but from South America as well.170 From this center, Dr Ruza has also promoted the teaching and high-quality research related to pediatric critical pathology The first PICUs in the Netherlands were established in the late 1970s and early 1980s at Rotterdam’s Sophia Children’s Hospital under Edwin van de Voort and Hans van Vught in Rotterdam PICUs were also developed at Wilhelmina Children’s Hospital in Utrecht and Emma Children’s Hospital at the Academic Medical Center in Amsterdam.171 These PICUs are multidisciplinary, and all are part of university teaching hospitals In 1995, the Dutch Pediatric Association established a section on Pediatric Intensive Care Medicine that certifies training of nearly all Dutch pediatric intensivists A nationwide transport system connects this centralized care system of pediatric critical care Units were opened in Germany172 and Slovakia173 as well as in Krakow, Poland, and many other European locations Israel Although located in the Middle East, Israel has traditionally been part of European scientific organizations, and most pediatric intensivists in Israel have trained in North America The first PICU in Israel was established in 1977 by Dr Zohar Barzilay as a fivebed facility located within Children’s Hospital at Sheba Israel now has 12 PICUs and two cardiac PICUs Extracorporeal membrane oxygenation services as well as cardiac transplantation are provided nationwide as part of the national health insurance program About 30% of the patients in many of the PICUs in Israel come from the Palestinian Authority Palestinian physicians trained in PCCM in Israel established the first PICU in Gaza.174,175 Latin America The first PICU in Latin America was established in Argentina at the Dr Ricardo Gutierrez Children’s Hospital in Buenos Aires in 1969 as part of a general surgery ward In 1972, Dr Jorge Sasbon became the first staff director of the PICU In 1972, a PICU was set up in Pedro de Elizalde Children’s Hospital, Buenos Aires, under guidance of Dr Clara Bonno.23 In Brazil in the 1970s, epidemics of polio and meningococcal disease, with a high mortality, led to the creation of small units for care of these patients These units were precursors of PICUs later established at Hospital das Clínicas São Paulo by Dr Anthony Wong (1977), at Hospital São Lucas in Porto Alegre by Dr Pedro Celiny (1978), at Hospital de Clínicas de Porto Alegre (1979) by Paulo R Carvalho, and in Rio de Janeiro In 1982, Dr Jefferson Piva opened a 13-bed PICU at Hospital da Crianỗa Santo Antonio in Porto Alegre.176 One of the pediatric critical care pioneers in Latin America was Dr Mauricio Gajer, a dedicated physician from Uruguay Dr Gajer traveled to France, where he worked with Professors Huault and Beaufils After returning to Uruguay, he created the first private PICU in Montevideo, Uruguay, in 1975 In Colombia, pediatric intensive care started in the early 1960s with postoperative care of cardiovascular patients in Clinica Shaio of Bogotá, with adult cardiologists in charge In the 1970s, Dr Merizalde, a pediatrician with training in pediatric cardiology, provided care for pediatric cardiovascular patients.177 In 1956 at Luis Calvo Mackenna Children’s Hospital in Santiago, Chile, a single-bed postoperative care unit was started by Drs Helmut Jager (cardiac surgeon) and Fernando Eimbecke (cardiologist) In 1968, this evolved into a five-bed PICU led by Dr Eduardo Bancalari, a neonatologist He was later joined by pediatricians Drs Patricio Olivio and Jaime Cordero In the 1980s, additional PICUs developed, including one with Dr Carlos Casar at Roberto del Rio Children’s Hospital in Santiago, Chile, later directed by Dr Bettina von Dessauer (pediatrician).178,179 Intensivists there have devoted great effort toward developing a network and transport systems to overcome the impact of Chile’s challenging geography Similarly, the first intensive care unit in San Jose, Costa Rica, was opened in 1969 at Hospital Nacional de Niños “Dr Carlos Sáenz H” as a postoperative cardiac care unit It was initially a nine-bed unit run by anesthesiologists and surgeons Eventually, pediatricians without special PCCM training became involved In 1982, Dr Aristides Baltodano trained in PCCM in Toronto, becoming the first pediatric intensivist in Costa Rica at Hospital Nacional de Niños “Dr Carlos Sáenz H.” At present, the PICU is a multidisciplinary unit with active cardiovascular and multiorgan transplant programs.180 Over time, a critical care network throughout Latin America has improved access, transport, and specific critical care knowledge in all countries However, there is still work to to facilitate access to critical care and achieve results comparable to those in high-resource countries Sociedad Latin Americana de Cuidados Intensivos Pediatricos (SLACIP) has played a crucial role Every years, a Latin American Pediatric Intensive Care Congress takes place A SLACIP symposium prior to each WFPICCS World Congress has become a tradition since the first world congress in Baltimore in 1992 The common language among more than 70 countries with many cultures and challenges forms a common bond CHAPTER 1 History of Pediatric Critical Care Medicine patients Accurate estimates of the extraordinary but often necessary financial costs of modern care of the critically ill child are difficult to obtain but are frequently substantial, even for life-years saved.130,131 Children with preexisting chronic disease and an acute critical illness have prolonged PICU stays, frequent readmissions, and the need for intensive care at home or in the rare pediatric subacute facility Most patients with these conditions did not survive in the 1960s and early 1970s Although many very sick children return to complete health, a small number, often with associated complex disorders, survive but live with chronic neurologic, respiratory, cardiac, or renal disease These children and their families usually require extraordinary medical and social support and advocacy to thrive As PICUs have evolved, intensivists have developed greater sophistication in dealing with individual family concerns, pain management, ethical issues, palliative care, social and spiritual needs,132 cultural differences, and the value of involving families as members of the team by including them on daily rounds.133 These issues are described in more detail elsewhere in this text Since the inception of PCCM, members of the team have experienced long hours of stressful work and occasional feelings of despair and frustration that their efforts are not making a difference This can lead to emotional distress and a sense of loss of fulfillment in their professional lives Understanding of this problem by local medical and nursing leaders helps the team members realize that they are making an important difference through their efforts and dedication, thereby reducing burnout and enhancing staff morale.134–136 Around the World People around the world have made many contributions to the evolution of PCCM, through innovative treatment of specific diseases, creating PICUs (see Table 1.1) and advancing education (see Table 1.2).137 See ExpertConsult.com for a summary discussion of the global origins of pediatric critical care High-Mortality Countries In 2013, 6.3 million children worldwide died before age years.181 Over 95% of these deaths occurred in high-mortality 13 countries of Asia and sub-Saharan Africa and 52% were caused by infections—especially pneumonia, diarrhea, and malaria— that could be prevented or treated at low cost.182 Asia, for example, is the world’s hot spot for the emergence and reemergence of infectious diseases that threaten the world’s population (i.e., severe acute respiratory syndrome, COVID-19, and influenza) but still has huge burdens of the traditional infectious diseases (malaria, tuberculosis, HIV, diarrhea, dengue, etc.) Asia also leads the world in the emerging and global export of drug resistance to many pathogens, despite undergoing a period of unprecedented economic growth Approximately 96% of children in the world live and die in resource-poor countries Replicating success demonstrated in many countries, as in India and elsewhere, will have an immense impact on national resources For example, in India, because of the high birth rates (annual births of 25 million) and large pediatric population (35% of total or approximately 300 million), as well as the need for trained people and material resources to service them, the required number of NICU and PICU beds would be enormous It would therefore seem prudent for all district hospitals (750 in the country) to be upgraded to provide level services that will meet the needs of rural communities.183 Increased access to PCCM for those at all economic levels should improve survival and eventually decrease the birth rate once people are more confident that their children will live Although the development of PICUs is essential for the overall improvement of child survival in developing countries, the high cost of intensive care limits patients’ access to PICU services.184,185 Basic and cost-effective care have proved to have a major impact on improving the survival of infants and children For example, a study in New Guinea demonstrated that the systematic use of pulse oximetry and supplemental oxygen reduced mortality from pneumonia by 35%.186 However, the cost was $51 for each child, which is beyond the means for many low-income countries where a high proportion of child deaths occur.187 Because hospital care is often not available to children in high-mortality countries, several authors have emphasized the need for preventive measures and improved primary healthcare.188–193 It is therefore important to train healthcare personnel and families in early detection of infants and children at high risk for mortality from infections and sepsis, which lead to critical disorders such as respiratory failure Prompt initiation of treatment can reduce the need for critical care services (Table 1.7) TABLE Accessibility to Pediatric Critical Care Medicine in High-Mortality Countries 1.7 Organization Program Purposes References Society of Critical Care Medicine Pediatric Fundamental Critical Care Support (PFCCS) Prioritize needs Appropriate tests Identify and respond to changing vital signs Need for transport 194, 195 Boston Children’s Hospital OPEN Pediatrics Free online educational platform 196, 197 American Academy of Pediatrics Helping Babies Breathe (HBB) Neonatal resuscitation 198, 199 American Hospital Association Saving Children’s Lives and Pediatric Emergency Assessment Programs (PEARS) Resuscitation training 200 World Health Organization Integrated Management of Childhood Illness (IMCI) Identify sick children early 201 14 S E C T I O N I Pediatric Critical Care: The Discipline Summary The evolution of PCCM has been long and complex It owes a great deal to innovations in anatomy, physiology, ventilation and resuscitation, anesthesiology, neonatology, pediatric general surgery and pediatric cardiac surgery, pediatric cardiology, and nursing as well as to the many individuals who advanced these fields around the world Any attempt to relate the history of PCCM is inherently incomplete Several individuals have been recognized for their contributions to PCCM in general and are noted in Tables 1.8, 1.9, and 1.10 TABLE Distinguished Career Awardees, Section on 1.9 Critical Care, American Academy of Pediatrics Year Name 1995 I David Todres, MD 1996 John Downes, MD 1997 Peter Holbrook, MD 1998 George Gregory, MD 1999 George Lister, MD 2000 Russell C Raphaely, MD 2001 Murray Pollack, MD 2002 Daniel Levin, MD Country 2003 Ann Thompson, MD Alan Conn, MD Canada 2004 Bradley Fuhrman, MD John Downes, MD United States 2005 J Michael Dean, MD Hans Feychting, MD Sweden 2006 David Nichols, MD Maurico Gajer, MD Uruguay 2007 Ashok Sarnaik, MD Gilbert Huault, MD France 2008 Patrick Kochanek, MD Seigo Iwai, MD Japan 2009 Jerry J Zimmerman, MD Max Klein, MD South Africa 2010 M Michele Moss, MD John Stocks, MD Australia 2011 Timothy Yeh, MD 2012 Niranjan Kissoon, MD 2013 Vinay Nadkarni, MD 2014 Barry Markovitz, MD 2015 Thomas Rice, MD 2016 Alice Ackerman, MD 2017 Richard Brilli, MD 2018 James Fortenberry, MD 2019 Fernando Stein, MD TABLE International Pioneer Awards World Federation 1.8 of Pediatric Intensive Critical Care Societiesa Name a Awarded Montreal, 2000 Acknowledgments We thank the following individuals and organizations for gathering material for this chapter and especially for helping us get facts and dates correct: Andrew Argent, Aristides Baltonado, Geoffrey Barker, Zahar Barzilay, John Beca, Jeffrey Burns, Gabriel Cassalett, Ira Cheifetz, Edward E Conway, Jr., Mark Coulthard, John Cox, Peter Cox, Robert Crone, Martha Curley, J Michael Dean, Bettina von Dessauer, Denis Devictor, Alan Duncan, Gideon Eshel, Alan Fields, Ericka Fink, Bradley Fuhrman, Melissa Fussell, Jonathan Gillis, William Glover, Denise Goodman, Thomas Green, George Gregory, David Hatch, Mary Fran Hazinski, Peter Holbrook, Robin Horak, Hector James, Tamara Jenkins, Niranjan (Tex) Kissoon, Max Klein, Patrick Kochanek, Jacques LaCroix, Jos Latour, George Lister, George Little, Kathryn Maitland, Barry Markowitz, Neil Matthews, M Michele Mariscalo, Peter Meaney, M Michele Moss, David Nichols, Hisashi Nikaidoh, Zehava Noah, Folafoluwa Odetola, John Pearn, Bradley Peterson, Jefferson Piva, Arnold Platzker, Bala Ramachandran, Adrienne Randolph, Russell Raphaely, Thomas Rice, Mark Rogers, Francisco Ruza, Hiro Sakai, David Schell, Frank Shann, Janice Bloedel Smith, Gregory Stidham, Sue Tellez, James Thomas, Neal Thomas, Ann Thompson, Ron Trubuhovich, Robert Tumburro, Edwin vander Voort, Amir Vardi, Dharmapuri Vidyasagar, Randall Wetzel, Gary Williams, Douglas Willson, Timothy Yeh, the American Academy of Pediatrics (AAP), the Critical Care Medicine Subboard of the American Board of Pediatrics (ABP), the American Council of Graduate Medical Education (ACGME), the American Hospital Association (AHA), the Children’s Hospital Association, the Society of Critical Care Medicine (SCCM), the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS), and the National Institutes of Health (NIH) In Memoriam: Dr Nick Anas, 1950–2018 ... La Paz in Madrid This center, directed by Dr Ruza, has served as a major training center for pediatric intensivists not only from Spain but from South America as well.170 From this center, Dr... their efforts are not making a difference This can lead to emotional distress and a sense of loss of fulfillment in their professional lives Understanding of this problem by local medical and nursing... opened the first multidisciplinary PICU in France at Saint Vincent de Paul Children’s Hospital This unit was the first pediatrician-directed PICU in Europe; it soon became a major influence on